Eye Banking in the 21St Century: How Far Have We Come? Are We Prepared for What’S Ahead? Donald J

INTERNATIONAL JOURNAL OF EYE BANKING LITERATURE REVIEW Eye Banking in the 21st Century: How Far Have We Come? Are We Prepared for What’s Ahead? Donald J. Doughman, MD; Cindy Christian Rogers, MA ABSTRACT PURPOSE: This review of milestones in eye banking describes efforts by the eye banking community to ensure the quality and quantity of corneal tissue over the last century and anticipates key challenges going forward. METHODS: This account draws on a review of the scientific literature, public documents, and eye banking sta- tistics and is augmented by the recollection of the author, discussions with eye bankers, and an analysis of press- ing medical and nonmedical issues that will bear on the future success of eye banking in the United States and internationally. RESULTS: The author identifies five eras of eye banking, highlighting scientific breakthroughs in surgical techniques, storage, and instrumentation; the professionalization of eye banks through development of medical standards and accreditation programs; and the advent of laws and regulations leading to reimbursement chang- es and donor legislation. The author next identifies five strengths exhibited by the community to achieve those milestones and delineates crucial questions posed by an ever-expanding array of unprecedented demographic, socioeconomic, geopolitical, biological, regulatory, technological, cultural, and ethical challenges. CONCLUSIONS: Technological advances and collaborative efforts have brought the eye banking community to the enviable position it enjoys today. Only by building on its historical strengths can eye banking professionals worldwide successfully evolve their role in an increasingly complex future. KEYWORDS: corneal endothelium, corneal preservation, corneal transplantation, eye banks, eye donation, healthcare economics reserving and restoring vision impaired by cor- on the healthcare delivery system in the United States neal disease, disorder, or injury have never been and elsewhere, the picture is about to change. Add to Pso routine as they are today in the United States, this mix an array of differing cultural expectations, more than 100 years after the first successful penetrat- religious practices, and ethical frameworks, not to ing corneal transplant was performed in 19051 in Eu- mention differing stages of economic development rope. Indeed, for most affluent countries throughout in less affluent countries, and the context for corneal the globe, healthy donor tissue and surgical services transplantation internationally becomes even more are readily available and, for many patients, reason- complicated. Are eye bank and medical professionals ably accessible. Emerging advances in instrumenta- prepared for what lies ahead? tion, surgical technique, and new materials hint at Given the numerous variables in play at this mo- more options and better outcomes for patients and ment in history, the launch of the International Jour- more efficient use of donor tissue by eye banks and nal of Eye Banking provides an opportune time to take surgeons. However, against a backdrop of shifting de- stock of where we have been, where we are, and where mographics, economic uncertainties, and pressures we are going. To this end, this paper (1) reviews the Author Affiliations: University of Minnesota Department of Corresponding Author: Donald J. Doughman, MD, Min- Ophthalmology and Minnesota Lions Eye Bank (Dr Dough- nesota Lions Eye Bank, 1000 Westgate Dr, Suite 260, St Paul, man); and medical writer/editor and corneal graft recipient MN 55114 ([email protected]). (Ms Rogers). International Journal of Eye Banking • vol. 1 no. 1 • Sept. 2012 • doi:10.7706/ijeb.v1i1.41 • © 2012 Regents of the University of Minnesota. All rights reserved. 1 www.eyebankingjournal.org LITERATURE REVIEW Eye Banking in the 21st Century: How Far Have We Come? Are We Prepared for What’s Ahead? technological advances of the last 100 years in tissue Patients undergoing ophthalmic surgical proce- procurement, storage, and surgical techniques and de- dures such as corneal transplants benefited from the scribes how they led to the proliferation of eye banks introduction of antibiotics in the 1930s and cortico- and medical standards, (2) mentions promising de- steroids in the 1940s, as well as the development of velopments in the field, and (3) identifies future chal- more refined surgical instruments and techniques. In lenges, including demographic, socioeconomic, geo- 1939, Weiner and Alois added a beveled edge to the political, ethical, and regulatory issues, made all the trephine, which was first developed by von Hippel more complex by differences among nations, regions, around the turn of the century, thus providing sur- and cultures. A review of this nature, of course, could geons with a tool for better dissection of donor tissue.5 fill a book; however, the purpose here is to sufficiently In Spain, the United Kingdom, Hungary, the United set the stage for the eye banking community to con- States, Switzerland, and Finland, prominent ophthal- sider what questions must be asked and answered as mologists championed corneal transplantation and we move into an uncertain future. continued to refine procedures. Technological advances led to finer sutures and needles; the introduction of the surgical microscope, a major contributor HOW FAR HAVE WE COME? to improving PK outcomes; and a more sophisticated understanding of the role of the cornea’s anatomy he trajectory of eye banking as a professional fo- and physiology, including the critical nature of the T cus has spanned not only many decades but also endothelium.5 many countries, and it represents the contributions of countless individuals dedicated to the mission of pre- The organizing years: 1945–1970 serving and restoring sight. It is perhaps simplest to The ability to store donor corneas even for a short summarize that history by differentiating key periods period of time allowed for the establishment of eye of growth. banks in which tissue could be collected and distrib- uted. The first of these organizations, the Eye-Bank for The formative years: 1935–1944 Sight Restoration, Inc., in New York, was founded in Until the 1930s, surgeons had but one source for pro- 1944 by Richard Townley Paton to “supply donor ma- curing tissue when they needed to perform a corneal terial to qualified surgeons, to support research in and transplant: the eyes of living donors who had been teaching of surgical techniques, to provide ocular tis- enucleated as the result of posterior segment patholo- sue for experimental work, and to stimulate research gy.2 Eyes had to be removed and corneas transplanted in the causes of blindness.”6 Thus, the concept of the immediately, owing to concerns regarding donor tis- eye bank came to be pioneered in the United States; sue death. Although surgeons used only clear corneas, by 1956, the cities of Boston, Philadelphia, Winston- outcomes were relatively limited due to factors such Salem, New Orleans, Chicago, San Francisco, and Los as primitive surgical techniques, intraoperative and Angeles had established eye banks. Moist-chamber postoperative complications, and limited pharmaceu- storage at 4°C continued to be the preservation meth- tical agents, among others. od of choice, while research into alternatives7 (e.g., The event that changed the course of penetrating drying, formalin fixation, freezing, freeze-drying, and keratoplasty (PK) and broke ground for what would liquid paraffin storage) did not produce satisfactory become eye banking occurred in 1937, when Russian results. ophthalmologist Vladimir Filatov reported that ca- During these organizing years, most of the devel- daver tissue stored in a moist chamber at 4°C could opment of eye banks individually as well as nationally successfully be used as donor material.3 Simple, con- continued to take place in the United States. Alson venient, and relatively inexpensive, this storage meth- Braley, the physician-founder of an eye bank in Iowa, od was a marked advance over using tissue from live is credited with stepping up eye banking to a new donors. Nevertheless, it had significant limitations, level of efficiency and reach when he organized vol- particularly the short-term survival of endothelial unteer ham radio operators into a national network cells, a critical factor in maintaining cornea transpar- focused on procurement and placement of eye tissue ency. As a result, corneal transplant surgery continued in the United States.2 Given the urgency of transplant- to be an emergency procedure. Surgeons grafted cor- ing corneal tissue as quickly as possible after donor neas stored at 4°C as soon as possible, usually 24–36 death, the ham radio network offered the most expe- hours post mortem.4 dient method of communicating between eye banks.8 Within 1 year of its founding in 1962, the Eye Bank International Journal of Eye Banking • vol. 1 no. 1 • Sept. 2012 • doi:10.7706/ijeb.v1i1.41 • © 2012 Regents of the University of Minnesota. All rights reserved. 2 www.eyebankingjournal.org LITERATURE REVIEW Eye Banking in the 21st Century: How Far Have We Come? Are We Prepared for What’s Ahead? Emergency Network had expanded to 60 operators had limited success in restoring useful vision and were working in 47 cities throughout 26 states.6 used primarily as a tectonic procedure to repair per- The proliferation of eye banks, run almost entirely forated corneas and globes. Meanwhile, Stocker11 re- by highly committed volunteers, also galvanized med- ported the importance

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